CLEVELAND, Ohio - Paula Chenevey of Wooster was working two jobs when she was diagnosed with breast cancer in 2012.

She was an adjunct professor at Stark State Community College and a massage therapist but neither provided her with health insurance. And, despite working two jobs, it was an expense she couldn't afford on her own.

Chenevey fell into the Medicaid coverage gap: She made too much money to qualify for Medicaid, but not enough to buy health insurance. That gap later was closed by the Medicaid expansion in Ohio, which now is at risk because of federal healthcare reform efforts and state budget changes.

"The misconception of the people on Medicaid is that they're not working," said Chenevey, who has held a job since she was 15. "People are working. People are trying really hard. Having a job doesn't always equate to having health insurance."

Chenevey's story is a snapshot of the hundreds of thousands in the state who were able to gain coverage through the Medicaid expansion.

Through programs like the Ohio Department of Health Breast and Cervical Cancer Project, Chenevey was able to get care until 2014, when she learned the cancer had metastasized, progressing into Stage IV. By then, though, Gov. John Kasich had approved the Affordable Care Act's Medicaid expansion in Ohio, and Chenevey was able to get actual health insurance.

She was one of more than 700,000 Ohioans who were able to gain coverage under the Medicaid expansion, coverage that let her get the treatment she needed to survive. The expansion allowed Ohioans age 19 to 64 with incomes at or below 138 percent of the poverty line to qualify. Before, only those who made less than 90 percent of the poverty level and were a parent, pregnant or disabled could get insured.

The 2017 federal poverty level for an individual is $12,060 annually, and the FPL for a family of three is $20,420 per year.

"My story is not unique; it's not special," she said. "These are real people, real working people."

Proposed changes to the Medicaid expansion at the federal and state level put people like Chenevey at risk for losing coverage and create a steeper benefits cliff for individuals and working families.

The Senate's Better Care Reconciliation Act, or BCRA, healthcare reform bill rolls back the Medicaid expansion starting in 2021 by gradually reducing funding over three years.

At the state level, the budget freezes Medicaid expansion enrollment starting July 1, 2018. Anyone not enrolled by that time will not be able to sign up and anyone who falls off the program because of churn or changes to income will not be able to reapply.

"It's very frightening to think about what might happen," said Chenevey. "That's just unthinkable - in this country at least."

When Arizona had a similar freeze in 2011, 70 percent of those enrolled were not on the program 1-1/2 year later. If Ohio were to see the same turnover, more than 500,000 people could lose coverage, according to numbers from the governor's office. In Cuyahoga County alone, that would mean roughly 70,700 people would fall off Medicaid, estimates Loren Anthes, a public policy fellow at the Medicaid Policy Center.

"The Medicaid freeze, as they're defining it, most likely inhibits economic mobility and engenders more dependency," Anthes said. "When people have coverage, they benefit economically, and they don't fall of the benefit cliff."

He said the freeze creates a disincentive for people to move off of Medicaid because they would lose more in public benefits than they would gain financially in accepting a raise or taking a better job.

The Center for Community Solutions models what that benefits cliff will look like in Ohio, using Scioto County, where expenses are close to the state median. (See charts)

"If you are a person at 90 percent of the federal poverty level with coverage, will you accept an extra dollar if it means you lose coverage?" Anthes said. "If they actually try to earn more per hour, it might make their net income go down. They'll basically run at a deficit, in terms of their household, because the public benefit is no longer there to help them."

The benefits cliff becomes especially problematic for seasonal workers, said Julie DiRossi-King, COO of the Ohio Association of Community Health Centers. Those workers often make enough money during a few months of the year to kick them off Medicaid, but then see their incomes drop significantly when that seasonal employment ends. Under the freeze, those individuals would no longer be able to get back on Medicaid.

"We're very concerned about that provision that's included in the state budget bill," DiRossi-King said. "We surely think it will undermine coverage opportunities for many of our low-income individuals and families."